The Book of Woe: The DSM and the Unmaking of Psychiatry Read Online Free PDF Page B

bright line and probably not worth the bother, that a good clinician can be trusted to determine significance and then, with the help of a decent diagnostic manual, figure out which disorder to diagnose and get on with the treatment. He was shooting from the hip, and even though I don’t regret reporting his comment, I can see why he wishes I hadn’t.
    On the other hand, metaphors often have significance beyond their author’s intent, although, as Freud pointed out, sometimes analysis is required to ferret it out. Fortunately for us, there is a philosopher of bullshit. His name is Harry Frankfurt, and he’s taught at Yale and Princeton, and in 2005 he published a tiny gem of a book called
On Bullshit.
“Bullshit is unavoidable 38 whenever circumstances require someone to talk without knowing what he is talking about,” writes Frankfurt. “Thus the production of bullshit is stimulated whenever a person’s obligations or opportunities to speak about some topic exceed his knowledge of the facts relevant to that topic.” Filling in the gap between opportunity and knowledge requires the bullshitter to stand “neither on the side of the true 39 nor on the side of the false,” he adds. “His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says.”
    For the last fifteen years, some of the smartest psychiatrists in the world, people who have studied diagnosis for their entire careers, people motivated, at least in part, by the desire to relieve suffering, have worked longer and harder, and taken more fire, than they ever expected as they revised the DSM-IV. But if you ask any one of them (and I have asked many) about the DSM’s diagnoses and criteria—new and old—he or she will tell you they are only “fictive placeholders” or “useful constructs,” the best the profession can do with the knowledge and tools at hand. They are fully aware, in other words, that their opportunity (although they may call it an obligation) to name and describe our psychological suffering far exceeds their knowledge. They have intentionally, if unhappily, stood on the side of neither the true nor the false, and for the sixty years since the first DSM was published, they have gotten away with it.
    I don’t mean to say that the DSM is nothing more than bullshit, or that the APA is merely trying to hoodwink us in order to maintain its franchise or make a buck (or a hundred million of them, which is what the DSM-IV has earned it). That would be as glib as tarring the entire diagnostic enterprise with Dr. Cartwright’s brush. And as uninteresting: finding bullshit in a professional guild’s attempt to strengthen its market position would be no more remarkable than discovering gambling in Casablanca. But what are neither glib nor uninteresting are the circumstances that make it necessary and possible for the 150 men and women on the DSM-5 task force and work groups to have it both ways, to manufacture fiction and yet act as if it were fact. If the story of the DSM-5 has any redeeming value, if it is more than a story about parochial disputes and internecine warfare, it is that it can reveal the conditions that motivate the publication of the DSM and the interests that another revision serves.
    Some of those circumstances are straightforward enough, and depressingly banal. If fully 10 percent of your guild’s revenue, and an uncountable amount of your authority, depend on a single book, a book that once saved your profession from oblivion and since then has brought it fabulous riches, you don’t give it up easily. But other circumstances are less obvious and more dangerous, and the idea that gives psychiatry the power to name our pain in the first place—that the mind can be treated like the body, that it is no more or less than what the brain does, that it can be carved at its joints like a diseased liver—is perhaps